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Báo cáo y học: " Laugh Yourself into a Healthier Person: A Cross Cultural Analysis of the Effects of Varying Levels of Laughter on Health"
Int J Med Sci 2009, 200 International Journal of Medical Sciences Research Paper 2009; 6(4):200-211 © Ivyspring International Publisher All rights reserved Laugh Yourself into a Healthier Person: A Cross Cultural Analysis of the Effects of Varying Levels of Laughter on Health Hunaid Hasan , Tasneem Fatema Hasan Mahatma Gandhi Mission’s Medical College, Aurangabad, Maharastra, India, 431003 Correspondence to: Hunaid Hasan or Tasneem Fatema Hasan, “Ezzi Manzil”, CTS No 3910, Near Bombay Mercantile Bank, Beside Amodi Complex, City Chowk, Juna Bazaar, Aurangabad, Maharashtra, India 431001 Email: hunaidhasan@hotmail.com or zainabhasan52@hotmail.com Phone: +91-240-234-8673/ +91-982-390-5866/ +1-905-826-3752 Received: 2009.05.01; Accepted: 2009.07.17; Published: 2009.07.28 Abstract This cross-cultural study explored along with various personality factors the relationship between laughter and disease prevalence Previous studies have only determined the effect of laughter on various health dimensions, whereas, this study quantified the level of laughter that was beneficial or detrimental to health There were a total of 730 participants between the ages of eighteen and thirty-nine years 366 participants were from Aurangabad, India (AUR), and 364 participants were from Mississauga, Canada (MISS) The participants were provided a survey assessing demographics, laughter, lifestyle, subjective well-being, life satisfaction, emotional well-being and health dimensions In AUR, a beneficial effect of laughter was mediated through moderate levels (level two) of laughter, whereas both low (level one) and high (level three) levels had no effect Similarly, in MISS, the beneficial effect was mediated through level two, but a negative effect was also seen at level three This could be attributable to a higher prevalence of bronchial asthma in western countries Laughter was associated with emotional well-being in MISS and life satisfaction in AUR, providing cross cultural models to describe the interactions between laughter and disease This study validated the correlation between emotional well-being and life satisfaction, with a stronger correlation seen in MISS, suggesting that individualists rely more on their emotional well-being to judge their life satisfaction In conclusion, there is a benefit to clinicians to incorporate laughter history into their general medical history taking Future research should consider developing mechanisms to explain the effects of level two, determine specific systemic effects and obtain more samples to generalize the cross cultural differences Key words: Levels of laughter, History-taking, Disease, Life satisfaction, Emotional well-being Introduction Laughter is an innate capability that not only helps humankind express emotion, but has also shown promise as a promotive, preventive and therapeutic measure to a wide array of medical ailments A study by Parse RR, structurally defined laughter as a “buoyant immersion in the presence of unanticipated glimpsings prompting harmonious integrity which surfaces anew through contemplative visioning” (1) Interestingly, this definition was inti- mately associated with the structural definition of health proposed by a phenomenological study of health consisting of four-hundred participants between the ages of seven and ninety-three years (2) Harmony, plenitude and energy were the three commonalities between both definitions (1) The study of laughter is known as “gelatology”, and its effects on health have become a popular topic in medical research (3) Mahony, DL, et al explored http://www.medsci.org Int J Med Sci 2009, various types of laughter that were thought to be health-promotive (4) The younger age group presumed laughter to be “strong, active, inhibited and loud”, whereas the elderly (mean age difference of 60 years) believed laughter should be “gentler, kinder, and less active” for its benefit on health Commonly, both groups, more importantly the elderly, found positive emotion to influence their laughter Neurophysioanatomy of Laughter The neuro-anatomical pathway for laughter has finally been understood after twenty years of research A single centre located in the dorsal upper pons controls two pathways, the “voluntary path” and the “involuntary path” otherwise known as the “emotionally-driven path” (5) The voluntary pathway begins from the premotor opercular areas and travels via the motor cortex and pyramidal tract to the ventral brain stem The involuntary path is comprised of amygdala, thalamic, hypothalamic, and subthalamic areas, in addition to the dorsal brain stem Moreover, the Society for Neurosciences has grouped the neuronal control of laughter into three components: cognitive area, motor area and emotional area The cognitive area, or the frontal cortex, comprehends various stimuli The motor area, identified as the supplemental motor cortex, generates a series of muscle movements needed for producing facial expression during laughter Finally, the emotional area, mainly the nucleus accumbens perceives and rationalizes happiness (6) Effects on Health [Cardiovascular System (CVS), Central Nervous System (CNS) Immunological System (IS), Respiratory System (RS)] Kataria M, at the School of Laughter Yoga, described laughter as a “powerful form of exercise that gives you more of a cardiovascular workout than many ‘regular’ aerobic activities (7) Similarly, two stages of laughter have been described, the arousal phase, elevating the heart rate, and the resolution phase, resting of the heart (8) Cardiologists at the University of Maryland found those patients who were suffering from myocardial infarction (MI) were 40% less likely to laugh However, laughter was shown to be prophylactic against MI Furthermore, an article by Miller M, et al at the University of Maryland found beneficial effects of laughter on the blood vessel This study consisted of twenty volunteers, where two video clips from both extremes of the emotional spectrum were shown At the end of the videos, the brachial artery constricted for five minutes and was then released In fourteen of the twenty volunteers the artery constricted after watching the 201 stress stimuli, and dilated in nineteen of the twenty volunteers after watching the laughter stimuli Moreover, the release of nitric oxide is considered vital for vasodilatation Mental stress was shown to degrade nitric oxide, and therefore, laughter minimized the negative effects of stress by reducing the break down of nitric oxide and thus, leading to vasodilatation (9) On average, laughter increased blood flow by twenty-two percent, and stress decreased blood flow by thirty-five percent (10) Immunity is a form of integral protection and defense against foreign agents Laughter had shown to affect the release of various immune mediators (11,12,13,14,15) Psychoneuroimmunological studies demonstrated connections between the brain and the immune system, such as the hypothalamic-pituitary-adrenal (HPA) axis and neural supply of lymphoid tissues (16) In a study performed by Berk LS, et al., they found increased blood levels of interferon-gamma in ten healthy fasting males after being shown a comedy video (p=0.02) (16) As a result, interferons have become a line of pharmacotherapy in viral infections, systemic carcinomas, hepatitis B and C, in addition to the development of antiretroviral drugs There are two types of stress: distress (the negative type), and eustress (the positive type also known as mirthful laughter) Distress was shown to increase stress hormones such as beta-endorphins, corticotrophins and catecholamines, but laughter (a form eustress) decreased these hormones, fortified activity of natural killer (NK) cells, activated T cells and B cells and increased Ig levels Thus, laughter is capable of combating the negative aspects of distress and fortifying the individual’s immune system to help fight against various immune mediated illnesses (11,12,13,14) Liangas G, et al associated the detrimental effects of laughter with bronchial asthma (17) Bronchial asthma can be triggered by: allergic reactions, various pharmacological agents, the environment, occupation, infections, exercise and emotions Laughter is composed of both a physical (exercise) and emotional component Perhaps, laughter, as a form of exercise and as an emotional response triggers bronchial asthma, and thus a potent stimulus Specifically, the physical aspect (exercise) of laughter was considered to cause exercise associated bronchial asthma which is prevalent at a later age (18,19, 20) According to Gayrard P, 52.4% of 143 asthmatics stated their attacks of bronchial asthma were induced by laughing (18) It was suggested, hyperventilation might be a cause to laughter-associated-asthma, in addition to stimulation of irritant receptors in the airway epithelium (17) The http://www.medsci.org Int J Med Sci 2009, second mechanism being the prevalent one admixed with the mechanism of hyperventilation seemed to appropriately describe laughter-associated-asthma The World Health Organization defined health as a “state of physical, mental and social well-being and not merely the absence of disease or bodily infirmity,” and provided a holistic approach in assessing health (21) An article by Richman J, offered insight into laughter and its role in mental and social health, both of which influenced each other in numerous ways (22) Furthermore, humans are social animals (23), and their state of mental health is influenced by various interactions in society Aims and Objectives This study examined the relationship between various dimensions of personality, levels of laughter and their effects on disease Previous research has approached laughter more experimentally However, this article focuses on bringing a systematic approach by incorporating various dimensions of personality to broaden the understanding of laughter and its application in clinical practice Therefore, the ultimate objective was to determine whether laughter history should be included as a part of routine medical history taking, and if whether questions related to an individuals’ level of daily laughter should be incorporated into a medical history to facilitate diagnosis, prognosis and management of various medical conditions Methods The study was approved by the ethics board of research at Mahatma Gandhi Mission’s (MGM) Medical College, Aurangabad (AUR) Participants A total of 730 young individuals between the ages of eighteen to thirty-nine were surveyed (24) This age group was selected to control for health conditions as a direct result of aging process Two culturally distinct samples were surveyed The first sample was from Mississauga (MISS), Canada representing an individualistic society, and the second sample from Aurangabad (AUR), India representing a collectivist society Markus HR, et al defined individualism as “an independent view of the self and an entity that is distinct, autonomous, self-contained, and endowed with unique dispositions” On the other hand, they also described a collectivist culture as an “interdependent view of the self as part of a larger social network, which includes one’s family, co-workers and others to whom we are socially connected” (25) Furthermore, Triandis HC, provided three criteria that would help distinguish an 202 individualistic society from a collectivistic one (26) The three criteria are: complexity, affluence and heterogeneity of society Most important to consider is “heterogeneity of society” Mississauga is an ethnically diverse society where two or more cultures coexist, this is considered to be heterogeneous in its composition, which is by nature more liberal and allows for individual expression (27) Therefore, the crux of individualism is the ethnic diversity of various individuals It is not the particular view of the individual that makes them an individualist, but it is the differing views of a group of individuals that makes an individualist society Conversely, Aurangabad is homogenous in its local dialect (Marathi), and socio-cultural environment for which it is considered collectivistic The first sample, from MISS, was comprised of 364 participants The participants included teachers and students from Rick Hansen Secondary School, and employees of local retail shops (Coast Mountain Sports, Mexx, Fairweather, Adidas, Living Den, Fruits & Passion, Tommy Hilfiger, Nutrition House, Benix, Grand & Toy, Purdy’s, Randy River, Bell World and Coles) and GlaxoSmithKline Inc (Departments: Solid Dose Manufacturing, Validation and Regulatory Operations) Moreover, post-secondary students were surveyed through an online survey website, Survey Monkey The online survey (http://www.surveymonkey.com/s.aspx?sm =tTYWdl431H8mcvtwvQIwuw_3d_3d) was presented in the same format as the hardcopy to ensure uniformity of results The email was sent to the prospective participants via a message (Subject: Tell us about your laughter) The various locations from where the surveys were obtained ensured heterogeneity of the participant’s cultural views, therefore representing a sample of an individualistic society The second sample, from AUR, was comprised of 366 individuals The participants included teachers and students at MGM affiliated colleges (MGM Medical College, Jawaral Nehru Engineering College, MGM’s Institute of Biosciences and Technology College of Agricultural Biotechnology and MGM’s Sangeet Academy) and employees of various retail shops (United Colours of Benetton, Cut, Accord Computers (P) Ltd Computer Mall, Reebok Shopee, The Mobile Store, Planet Fashion Van Heusen, Levi’s Store, Cotton King (P) Ltd., Pepe London and Catmoss Retail Ltd) As a participant, English literacy was a minimum criterion An English language based survey conferred that participants fully understood the questions and completed the survey on their own without assistance This helped reduce differences between the adult literacy in MISS (literacy rate of 99.0%) and AUR (literacy rate of 61.0%) (28) http://www.medsci.org Int J Med Sci 2009, Before administering the surveys, a letter providing institutional affiliation, purpose of the study and declaration of anonymity and confidentiality was presented to all participants After completing the survey participants were given a briefing about the study Any incomplete surveys of the relevant information were discarded Survey The survey consisted of thirty-two questions, titled: Self-Report: Laughter and Health It obtained details about the participant’s demographics, laughter, lifestyle, and subjective well being consisting of life satisfaction and emotional well being, and an assessment of health dimensions Components of the Survey Demographics Demographics pertaining to age, gender, city of residence, annual income, and education were included Specifically, age, gender and city of residence defined the parameters of the samples Measurement of Laughter Laughter was assessed by two questions, Laughter Q1 and Laughter Q2 Laughter Q1 How many times you laugh in one day? 0-5 times; 6-10 times; 11-15 times; 16-20 times; 21-25 times; 25 laughs and more Participants were to reflect upon their laughter history before providing their answer It was difficult to remember an accurate number of laughs; therefore, in attempt to reduce the error in judgement, the numbers of laughs were grouped into six ranges These ranges categorized individuals into low, moderate and high levels of laughter, namely, level one, level two and level three respectively Furthermore, the human mind consists of two elements: the conscious and unconscious The conscious mind explicitly assesses situations, whereas the unconscious mind remains implicit (29) Thus, this question expected a conscious appraisal of the participant’s level of laughter, but, the nature of the question evoked an unconscious response Laughter Q2, referred to as situational laughter, measured laughter in the following scenarios: When the individual hears a joke When the individual watches a comedy When the individual is with family/relatives When the individual is with friends During the individual’s regular day For each situation, the participant was required to rate their level of laughter on a scale of one (don’t laugh) to ten (uncontrollable laughter) This question 203 represented the common daily scenarios in which an individual would most likely laugh This scale required a conscious appraisal of the participant’s level of laughter and expected to be less influenced by the unconscious mind and memory biases Three levels of laughter categorized the participants into low, moderate and high Laughter Q1 consisted of six ranges from which they were grouped into three levels: level one (range one and two or 0-10 laughs), level two (range three, four and five or 11-25 laughs) and level three (range six or 25 laughs and more) Likewise, in situational laughter, Laughter Q2 consisted of a scale from one to ten and was divided into three levels, level one (1-3), level two (4-7) and level three (8-10) Both methods of measurement were equally important to validate the results of laughter Three different sets of responses were encountered Firstly, responses to both questions corresponded to the same level of laughter, and thus, it was accepted Secondly, for instance if a response belonged on the two extreme levels of laughter, like the response to Laughter Q1 was level one and the response to Laughter Q2 was level three or vice versa, an average was taken, and level two, was accepted Finally, if responses belonged to adjacent groups such that, the response to Laughter Q1 was level two, and the response to Laughter Q2 was level three, the authors accepted level three as the response, because they gave situational laughter precedence in this situation while accepting the appropriate level of laughter Lifestyle Questions concerning lifestyle were included to explore the various other factors that influence health The section on lifestyle contained seven questions The first five questions were related to general lifestyle Lifestyle Q1 How aware are you about your health? (lowest) -10 (highest) Participants were made to cognitively self-evaluate and perceive their own level of awareness for their health Lifestyle Q2 How socially active are you? (lowest) -10 (highest) Lifestyle Q3 How active are you in your community? (lowest) -10 (highest) In reference to Q2 and Q3, Aristotelian Darwinian’s viewed human beings as social animals by nature (23) Since humans are innately programmed to be social, it was therefore vital to assess the participant’s social and communal involvement Lifestyle Q4.How physically active are you during the day? (highest score) Active with Daily Exercise http://www.medsci.org Int J Med Sci 2009, - Not active (score of zero) The response was two-fold, comprising of an objective and subjective component Whether they were active or not, was subjective, and how frequently they exercised, was objective Lifestyle Q5 How aware are you about your daily diet? (highest score) I am well aware and I eat a well balanced diet - I am not aware and don’t eat a well balanced diet (score of zero) The response was two-fold, comprising of an objective and subjective component The awareness about their diet was subjective, and whether they ate a well balanced diet was objective These five questions were amalgamated to form an overall score for lifestyle The total score was thirty-seven Lifestyle Q1 to Lifestyle Q3 were equally weighted and represented 81% of the total value of the questions, whereas, Lifestyle Q4 and Lifestyle Q5 represented only 19% This gave an appropriate level of emphasis on Lifestyle Q4 and Lifestyle Q5, without overestimating its influence Please note that these five questions were not intended to be a complete assessment, but a brief overview of the participant’s lifestyle Subjective well-being According to Schimmack U, et al., subjective well-being is comprised of a cognitive component, life satisfaction, defined as one’s life according to subjectively determined standards, and an affective component, emotional well-being, is defined as the balance between pleasant affect and unpleasant affect (30) Life satisfaction included satisfaction of occupation, marriage and life in general, and emotional well-being consisted of mood and self-esteem Laughter and personality were correlated through a neurobiological circuitry, which subsequently affects emotional well-being (31) The two questions specific to life satisfaction were: Life satisfaction Q1 How satisfied are you with your life? (lowest) -10 (highest) Life satisfaction Q2 How satisfied are you with your occupation? (lowest) -10 (highest) Life satisfaction and occupation satisfaction were included in this study Marital satisfaction was not included because of social limitations, therefore minimizing any erroneous effects on the study Also, a significant number of participants were not married While assessing emotional well-being, mood and self-esteem were crucial elements to consider The three questions were: Emotional well-being Q1 How you feel at the moment? (sad) 1—2—3 (happy) Emotional well-being Q2 How would you de- 204 fine your mood generally? (sad) 1—2—3 (happy) Emotional well-being Q1 and Emotional well-being Q2 inquired about the participant’s present and general mood and its aggregate was a more appropriate indicator Emotional well-being Q3 In general, what you believe about yourself? (highest score) I am a good person and very valuable to my society - Who am I? I don’t know how I affect society (lowest score) Emotional well-being Q3 was specific to self-esteem Self-esteem of an individual consists of two components: self evaluation, feeling of self worth (32) Self evaluation was assessed by asking the participant if they were a “good person”, “not a good person” or “not sure about who they were” The self worth component assessed how valuable the participant believed they were to their society, such as “very valuable,” “not valuable” or “not sure” An aggregate of mood and self-esteem provided an overall score for emotional well-being Health Dimensions This section of the survey inquired about the participant’s history of past illnesses The participants were asked to indicate “yes” or “no” if they had suffered a medical condition pertaining to CVS, RS, gastrointestinal tract, hepatobiliary system, genitourinary system, reproductive system, CNS and psychiatric conditions, and then to specify the name of that condition If the participant failed to indicate the name of the condition regardless of a “yes”, the survey was discarded assuming the participant did not fully understand the question Statistical analysis The data was analyzed using both parametric and non parametric statistics and the specific test used was indicated with the respective results If assumptions of normality and equal variances (Levene’s test) were accepted, then parametric statistics would be appropriate method for analysis, otherwise non parametric statistics were used Correlations for all categorical data were performed by Contingency Coefficient (R) test Accepted value of statistical significance for all analysis was α=0.05 Results Preliminary Analysis Mann Whitney U test was performed to make a statistical valid comparison between age and gender distribution in both samples (Table 1) Both samples were not statistically different from each other with respect to age (Z=-1.32, p=0.129) and gender (Z=-0.228, p=0.820) Disease process was influenced http://www.medsci.org Int J Med Sci 2009, 205 by both age and gender, thus equality in distribution for both factors between both samples was essential for further analysis Table 3: Life Satisfaction statistics City No disease Disease M SD M MISS 14.41 3.4 13.56 3.41 0.015 0.902 2.336 0.02 AUR 15.46 3.57 15.26 3.51 0.874 0.351 0.481 0.631 Table 1: Demographics of the sample City n MAGE(years) SDAGE(years) Male (%) Female (%) MISS 364 22.50 5.11 54.1 45.9 AUR 366 22.37 4.43 58.7 SD Levene's test No disease-disease comparison F p-value t p-value 41.3 Total 730 According to Table 2, the presence of disease was statistically greater (χ2=16.00, df=1, p0.01) MISS showed a greater percentage of participants in level one as compared to AUR Furthermore, AUR had a greater percentage of participants in level two, as compared to the MISS However, AUR and MISS were almost equal for level three The survey also included a set of questions, titled “Lifestyle” The aggregate score in MISS was significantly greater than AUR (t=4.105, p